Robert Alan Vogel, MD: a conversation with the editor*

ROBERT ALAN VOGEL, MD: A Conversation With the Editor* ob Vogel is Professor of Medicine and Director, Clinical Vascular Biology at the University of B Maryland School of Medicine in Baltimore. He was born in New York City in May 1943, graduated in 1963 from Columbia University, magna cum laude, with a BA degree in physics, and from Yale University School of Medicine, cum laude, in 1967. His internship and residency in internal medicine and his fellowship in cardiology were at the University of Colorado Medical Center. Following completion of his training, he joined the faculty at the University of Colorado School of Medicine and remained there until 1980 when he went to the University of Michigan School of Medicine in Ann Arbor. In 1985 he became full professor. In 1987, he moved to Baltimore to be the Herbert Berger Professor of Medicine at the University of Maryland School of Medicine and head of the Division of Cardiology. In 2000, he became director of clinical vascular biology at that center. Dr. Vogel has published over 180 articles in medical journals, 50 chapters in various medical books; he has coauthored 1 book and authored another. He is also a great guy. William Clifford Roberts, MD† (hereafter WCR): Earlier today (7 October 2003) Dr. Vogel gave grand rounds at Baylor University Medical Center and his topic was “The Vascular Biology of Coronary Risk Factors.” It was clearly the best talk on risk factors I’ve heard. After this interview, he will speak at the medical residency conference on “Food and Wine as Medicine.” (Figure 1) Bob, I sincerely appreciate your honoring us at Baylor University Medical Center by your visit. Last night we had a dinner in honor of Dr. Vogel with about 25 people. Let me start by asking you about your parents, your siblings, and some of your early memories. What was life like growing up in New York City? Robert Alan Vogel, MD‡ (hereafter RAV): There are 2 things that I remember very vividly about my early childhood. The first was, of course, my parents. (Figure 2) My parents were quintessential public school teachers. They loved children and they loved education. Our discussions at dinner were about books and ideas. The public school system in New York City at the time was both very challenging and supportive. I remember learning how to calculate square roots manually in third grade. I remember many of my teachers throughout grade school as being really interested in our intellectual development. That environment was a fortunate upbringing (Figure 3). *This series of interviews is underwritten by an unrestricted grant from Bristol-Myers Squibb. † Baylor Heart & Vascular Institute, Baylor University Medical Center, Dallas, Texas 75246. ‡ Department of Medicine, Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland 21201. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 April 1, 2004

I also remember well my summer camping experiences. When I was young, my father was the head counselor at a summer camp in Vermont. I spent all of my summers through college except one at camp, going there long after my father stopped. The camp was very inclusive, being interracial, interdenominational, and international. We had emotionally and physically challenged campers. The camp had 2 special sides. One was an early “outward-bound” emphasis (Figure 4). We were very venturesome and selfsufficient kids. We would canoe and mountain climb with minimal supervision for more than a week at a time. Getting lost in the mountains or swamping canoes in a hurricane in Lake Champlain just didn’t phase us. The other emphasis was spiritual, not in a religious sense, but in terms of moral behavior. Every weekend, we had discussions about doing the right thing in various circumstances. I still remember those discussions. They were very much a part of my upbringing. I enjoyed the school terms and went camping all summer. It was a very good upbringing. WCR: What would be an example of an episode that you just mentioned at camp that would give ethical leadership? RAV: As kids, we were always getting into some sort of trouble. The camp cow just might end up getting stranded on the swimming raft. There were no punishments, but there were lots of open discussions. We learned to have a sense of consequence. The process of airing out situations developed a sense of ethics and morals that has stood well with me. We learned to do the right thing simply because it is the right thing, not because of fear of getting caught or punished. WCR: What did you father and mother teach? RAV: My father also grew up in New York City. He studied chemistry in college during the Depression, but was unable to get a job as a chemist and went into teaching. He initially taught elementary school and within a relatively short period became a principal of an elementary school. My mother taught fifth grade for almost 40 years. WCR: When was your daddy born? RAV: Dad was born in New York City in 1901. He grew up fatherless. He worked his way through grade school, college, and graduate school while supporting his mom. He was always a very hard worker. He was both brilliant and very artistic. We still have scores of his beautiful watercolor paintings in our house. These paintings are quite a legacy from him. WCR: He died when? RAV: He died in 1977 from a brain tumor. He had a seizure in the mid-1960s while I was in medical school. We knew that the most likely cause was a brain tumor, but this was before computer tomographic scanning. Our diagnostic procedures were 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.01.016

891

limited to pneumoencephalography and angiography, and we were unable to find the tumor that we knew he probably had. By the time computer tomography was available, the tumor was quite large. Although he had several more good years after surgery, it took its toll. Knowing the importance of good diagnostic techniques probably influenced my early interest in developing single photon tomography. WCR: Were your father’s parents born in this country, or if not, where did they come from originally? RAV: My father’s parents were born in Vienna and emigrated to the USA in the 1890s. I knew nothing of my grandfather on my father’s side. I remember my grandmother quite well. She was very much a typical Jewish grandmother. My father was her only child. WCR: Your father’s father died when he was quite young? RAV: The marriage broke up and to this day we know very little about my father’s father. WCR: When was your mother born? RAV: My mother was born in 1907 and is still alive. She’s almost 96. She also grew up in New York City. Her parents had emigrated from Kiev, Russia to escape the Czarist pogroms of the time. My grandfather on my mother’s side became active in New York City government and was secretary of elections. He was a very energetic man and lived to quite an old age. He developed coronary disease at an older age, and had a “Vineberg” procedure. That was my first introduction into coronary disease management. My grandmother also lived to be quite old. My mother is a remarkable person. She grew up in New York City in a very traditional, male-domineering household. My father also was very domineering. Although she worked for many years, my mother was not allowed to drive, write a check, or know anything of finances. When my father died, my mother was 67, at which time she learned to drive, started running her own finances, and began traveling alone. She remained independent until age 95, living in the house in which we grew up. She has only recently moved into a senior facility that provides assisted living. WCR: Where did you grow up in New York? RAV: I was born in Brooklyn and lived in East New York, near Highland Park, until I was 7. We then moved to Flushing in Queens and lived there until I went off to college. I went to Bayside High School and Columbia College in Manhattan. So, I really grew up in Brooklyn, Queens, and Manhattan. WCR: Do you have siblings? RAV: I had 1 sibling, a sister 2 years older than I. She was killed in a pedestrian/automobile accident in 2000. That event had a tremendous impact on me in terms of understanding what’s important in life and the fragility of life. It was very hard getting a call one night learning that my sister had literally stepped off a curb and was killed by a truck. We were a small family to start out with. My sister was born in 1941 and, in the tradition of our family, went into teaching. She taught for a few years and then retired to raise a family. WCR: Where did she live? 892 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

FIGURE 1. RAV at time of interview (photo by WCR).

RAV: She lived in Chicago, London, Tokyo, and finally San Francisco. She was married to a successful banker, a very charming fellow. Together they had 4 children. WCR: What was home life like when growing up in New York City? RAV: In Brooklyn we lived in a small apartment. We moved to Queens when I was 7, into a nice house with a back yard. There were many kids my age around and we played in the streets, open lots, and parks nearby. WCR: Did you have a room of your own? RAV: Yes. I really had 2 rooms. One was my bedroom. I also took over the basement in which I had all kinds of electronic equipment that I had bought for pennies on Canal Street. I built all kinds of things. WCR: Like what, for example? RAV: I built several radios, the first of which was a crystal set. My last project in high school was an early computer that would calculate projectile trajectories. That turned into a science fair project written up in The New York Times. I’d always have some kind of building project going on or a deciphering project to see how something worked. My mom tells that when I was 2 or 3 years old, I would put together model cars and airplanes from kits by looking at the instructions. Model building has always been an on and off hobby of mine. When I was in Michigan I built and flew radio-controlled airplanes. APRIL 1, 2004

WCR: What other interests did you have as a young

boy? RAV: I have always liked playing sports. I swam competitively through college. I have played tennis since I was 10 years old and still play with Mike Didolkar, a surgical oncologist. We’ve gone at it once a week for the last 16 years. On any given night, we don’t know who will win. I love to ski in Colorado and play golf whenever I can. These interests may be a legacy of the time that I spent in camp. Being physically active is very important to me. WCR: When growing up, you started your day in the swimming pool? RAV: Yes, swimming. After that I went to classes. Swimming was not a big part of what I did in high school. It became a bigger part of what I did in college because I had to train so much harder and twice a day. WCR: What events did you swim? RAV: I swam the 200-yard butterfly and the 100yard freestyle. WCR: Did you play competitively in other sports in high school? RAV: No. That was the only sport that I competed in. WCR: Did your high school have a swimming team or did you do that outside of high school? RAV: Outside. At Columbia University all incoming students had to pass a swim test. Although I had been a swimmer, I was not terribly competitive. Dick Stead, the swimming coach at that time, watched all the kids swim. He came up to me afterwards and said, “Okay. Bob, you’re going out for the swim team.” Not really knowing what competition on the college level was, I gave it a try. It turned out to be great fun. I wasn’t terribly good for 1 or 2 years, but I got better. By my senior year I was on a record-setting freestyle relay (Figure 5). WCR: How tall are you and how much do you weigh? RAV: I am 5 feet 7 inches tall and I weigh about 140 pounds. WCR: Is that what you weighed then? RAV: I weighed even less then, about 125 pounds. I was always one of the smallest kids in the group. WCR: What was home life like when you were growing up and went to school? When you came home your parents weren’t there, or did they get home about the same time as you did? RAV: My parents were generally not there. The first thing I would do was go out and play with my friends. Play might mean building a rocket or biking down to the park and start a pickup game of softball or whatever. We kids entertained ourselves and were generally not expected home until dinner. Dinner was always our family together. My parents liked to discuss a variety of things at the table. It wasn’t just what we did during the day. We talked about current events, religion, or politics. We were always talking about something. After dinner I did homework. We didn’t have a television set until I was in junior high school. WCR: Did your father and mother ask you and your

FIGURE 2. RAV at age 8 with father Leonard, mother Sylvia, and sister Janet.

sister questions at dinner, or would it be sort of an easy free-type discussion? RAV: They didn’t quiz us. We simply talked about something of interest to them or what we were doing with our friends. WCR: Was religion a major part of your growing up? RAV: To my family, yes. I grew up in a reformed Jewish household. My father taught Sunday school. I was bar-mitzvahed and confirmed in the Jewish religion. By my mid-teenage years, however, I increasingly saw organized religion as a factual contradiction. The concept of 50 religions, each saying “we are right and they are wrong” has always been problematic for me. We were asked to read Jacques Barzun’s The House of Intellect the summer before college. That book crystallized my thinking about organized religion. I still think of myself as a spiritual person. That point of view is one of the many core beliefs that I share with my wife—many of the same values. Religion for us is simply good behavior and appreciation of the gift of life, not orchestrated beliefs. She came to the same place from Catholicism that I came to from Judaism. WCR: You obviously did well in school. Did studies come easy for you? Were they enjoyable for you, or did you have to work pretty hard to get those good grades? RAV: Studies generally came very easy to me. My INTERVIEW/ROBERT ALAN VOGEL

893

FIGURE 3. RAV (second from the left, front row) with other middle school science fair winners.

sister did very well in school but worked very hard. I did well, but most subjects came easy. I was especially interested in math, science, and history. As high school seniors, my friend Bob Kirk and I won the annual city-wide science competition. Neither Bob nor I studied much. We just read, usually not what we were studying in class. WCR: Were there a lot of books around your house while you were growing up? RAV: Our house was loaded with books, all different kinds of books— classic novels, how-to books, magazines. I have always collected books on doing this or that. We were always reading and writing. To this day, writing, especially technical writing, is one of my favorite activities. WCR: Was your mother or your father the big reader, or were they both? RAV: They were both huge readers. To this day, my mother spends most of her time reading. She has never been much of a television watcher. My father was a reader. He would get up very early, about 5 A.M., and read the paper and then other things. WCR: Did you go as a family on vacations, other than camp, as you were growing up? RAV: We had a lot of family trips together. I remember going to Williamsburg, Mount Vernon, Washington, DC, Boston, and other places as a family. As you would expect, we visited mostly educational 894 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

sites. We concentrated on the museums and the historic sites. In contrast, summer time was the fun time at camp. WCR: What about Saturdays and Sundays in New York City when you were growing up? Did you frequent the museums in the area? RAV: We went to museums, plays, and music events frequently. We really took advantage of New York. After I went to college, my parents continued to go to cultural events often. Weekends also meant lessons. I took music, painting, and sculpture lessons, almost always on the weekends. Although I was a reasonable painter, I was a total failure in music. I tried for many years to learn to play the clarinet without much success. To this day, I envy anyone who can sing on key. WCR: Getting into Columbia University for a New York boy must not have been easy. How did it come about that you went to Columbia? RAV: I had actually spent some time at Columbia. One of the nice things about the schools in New York at that time was that they allowed students to progress as rapidly as they were able. When I was in high school, I had a physics class of only 5 or 6 students. It was very advanced. We were encouraged to take college courses in high school. One of the reasons that I went to Columbia was that I had spent some time there APRIL 1, 2004

RAV: My Columbia experience was very enjoyable on many different levels. Columbia required all students to take core liberal arts classes. They were intellectually stimulating and enjoyable. In my major, I was given the freedom to design some of my own projects for credit. The swimming team was an immensely enjoyable experience and the social experience of living on my own with other students in New York City was great fun. WCR: What did you major in? RAV: I majored in physics. Physics at Columbia was very popular, but challenging. Only about 30 of the 100 or so physics majors stuck it out. One B grade meant you weren’t competitive. My college advisor, Melvin Schwartz, had a big impact on me. He is a particle physicist who won the Nobel Prize in 1988. He took a personal interest in me and allowed me to design my own thesis for credit. He was very disappointed when, in my senior year, I told him I wasn’t going into physics, but into medicine. WCR: How did you get interested in medicine? Were there any physicians in your family? FIGURE 4. RAV as a Camp Kokosing counselor leading a hike on New Hampshire’s RAV: My mother’s brother, who is Mt. Washington. still alive, was an otolaryngologist in New York City. He now lives in Florida. He was my only role model. He in high school. Columbia thus knew me a bit. I did was a graduate of the University of Maryland. I supreasonably well in high school. pose that that had some impact on my going to BalWCR: How many graduated in your senior class in timore. I’d always planned to go into science, probahigh school? bly physics. During the summer after my junior year, RAV: About one thousand. The New York City I went to UC Berkeley to do some additional work in high schools are very large. physics. For the first time, I saw what physicists WCR: Where did you stand in your high school actually did. I came back with the feeling that physics class? was something wonderful to study, but wasn’t so RAV: I was number 3 or 4. terrific in terms of day-to-day activities. I came back WCR: Your teams in high school must have been and said, “Okay. I’d like to do science. What am I incredibly good with that large a number of students? going to do now?” This was an era when young people RAV: Yes, but they were competing with lots of really thought about social responsibility. I decided to other schools that had just as many students. Our go to medical school for the human impact and apteams were okay. I don’t remember winning a city plied to a few schools. I got into Stanford and Yale without having taken any premed courses. I picked championship in any sport while I was there. WCR: Did you apply to universities other than Yale because it was 4, not 5, years and because it had no exams. Columbia? RAV: I applied to Princeton and Harvard, but did WCR: How many were in your graduating class at not get into either of them. Columbia? WCR: When you went to Columbia, did you live at RAV: About 600. home or did you board at school? WCR: So less than your high school? RAV: I lived in the dormitory the first year. Then I RAV: Yes. My college was smaller than my high went in with 5 Columbia and Barnard students and got school. an apartment which was about a block off campus. WCR: Do you have any idea of your class standing Living off campus in New York at 17 was great fun. among those 600 when you finished? WCR: Your Columbia experience was an enjoyable RAV: Not really. I was very competitive in science one? and math and graduated magna cum laude and Phi INTERVIEW/ROBERT ALAN VOGEL

895

FIGURE 5. RAV (center, front row) on the 1962 Columbia College record-setting, 400-yard freestyle relay team.

Beta Kappa. I was the Eisenhower Scholar at Columbia my graduating year, which meant that I was the highest ranked varsity letter winner. Dwight Eisenhower had been a former president of Columbia and gave an engraved watch to the winner each year. WCR: Do you remember any teachers in junior high or high school or college who had a major influence on you? RAV: In junior high school, my favorite teacher was Mrs. Rosenfeld. She was my English teacher for 2 years. She taught us how to express ourselves with precise vocabulary filled with adjectives and adverbs. Of course, in college we had to quickly learn simple declarative sentences. In retrospect, an incident in her life had a large impact on me. Her husband died of cancer while she was my teacher. Being friendly with her, I could see the impact that illness had on her. Thinking back on my decision to go into medicine, Mrs. Rosenfeld probably sowed the seeds. My physics teacher in high school, Mr. Barr, also had a large impact on me. My high school allowed a few students at a time to work closely with a few teachers. Mr. Barr really nurtured my interest in physics. We had small classes and advanced studies. Math studies were very similar. In high school, we did 1 year of trigonometry in a semester and then moved on 896 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

to spherical trigonometry. We did college-level calculus in high school. This was a tradition in the New York City public school systems at the time. They would really challenge kids. WCR: Were you in the smart kid’s track early on in school? RAV: There was an academic track certainly by junior high and it continued into high school. I was in a program that allowed us to do middle school in 2 years rather than in 3, the standard time. WCR: That’s why you were able to graduate from college at age 20 rather than at age 21? RAV: Yes. WCR: What about in college? You mentioned Dr. Schwartz. Were there others who had an impact on you? RAV: Yes. Another Noble Prize winner at the time was Polycarp Kusch, also a gifted teacher. The intellectual incentive we got in science and math at Columbia was extraordinary. These professors were very good teachers and actually spent time with the students. WCR: How often did you swim at Colombia? You mentioned earlier that it was sometimes twice a day. RAV: Morning and afternoon. WCR: What time did the morning start? APRIL 1, 2004

now is a retired cardiac surgeon and has established a program for teaching heart-healthy lifestyles in high school, college, and in the pro sports. He does risk factor screens and teaching. The program has screened the post-9/11 New York City policemen. I’m going to assist him later this year in doing risk factor screens on the Washington Redskins and Baltimore Ravens football teams. The concept is that if professional sports can get interested in cardioprotection, so can college sports, and then the high school teams. As you know, I have a real interest in preventive medicine. The challenge is to get this information out to the public. Perhaps this role model concept will help. WCR: Where is Archie’s program? RAV: Archie’s program is in New Jersey, but it’s a national program. WCR: He was a great athlete. RAV: Archie was a terrific athlete. We were football co-champions of the Ivy League for 1 year then. But it wasn’t the “Big 10” or the “Pac 8” by any stretch of imagination. Some of the sports at Columbia were OK. Some of FIGURE 6. RAV’s first mentor at the University of Colorado, Peter Steele. them were competitive. Football was reasonably good. Basketball was pretty RAV: Morning would start at 7:00 A.M. I’d swim good. Fencing was always terribly good. After I left, before 9:00 A.M. classes and then in the afternoon swimming got pretty competitive for a while. either at 4:00 or at 6:00 P.M. Instead of going home for WCR: David Hillis of Southwestern Medical School Christmas or spring vacation, I stayed at Columbia here in Dallas was at Columbia the same time you and swam. were. He played on the football and baseball teams with Archie Roberts. WCR: How many were on the swim team? RAV: About 20. It was not a very big team. RAV: Archie was 2 years ahead of me. I didn’t WCR: You must have been incredibly pleased with know David, but we would have overlapped. your ability to make the team. WCR: How did you decide to go to Yale University RAV: Bill, it wasn’t the best team. It was a college School of Medicine for medical school? team, but swimming at Columbia at that time wasn’t RAV: I applied to a few programs and got into most terribly competitive. We swam in the Ivy League, but of them. The decision for me came down to Stanford would only beat 1 other school or so each year. We or Yale. I made the decision for Yale because (to this would generally beat most of the local schools, day) they have no exams other than the National Fordham, City College, the Coast Guard Academy, Boards that students are required to take. I liked that etc. It was still great fun. Columbia has a tradition of kind of program. We studied at our own pace and doing sports for sport’s sake. Remember that Colum- learned because it was a good thing to do. This apbia still holds the longest consecutive losing series in proach is the exact opposite of most medical schools, football of any major college. I think they lost 42 in a but it suited how I liked to learn. We were required to row. My concept of a student athlete may be a little bit do an extensive research project that bordered on a different from the norm. I think sports are important thesis. I developed a tracer method for measuring in for the effort and values they teach. I really never utero hemoglobin. It was a good academic experience thought of myself as being a terribly good swimmer or and my time at Yale was very enjoyable. on a terribly good team. I had the chance to swim WCR: How many were in your class at Yale medagainst some truly world-class athletes, which was a ical school? humbling experience. RAV: Approximately 70. WCR: Football, when you were there, was a pretty WCR: You graduated from medical school in 1967? big deal? RAV: Yes. RAV: Football was pretty good. We had a very WCR: Do you remember when you first entered good quarterback by the name of Archie Roberts. medical school? These first few days, what were some Archie went on to play pro ball for a year or 2. I bring surprises for you? up his name because he’s still a friend of mine. Archie RAV: Not having been premed, medical school for INTERVIEW/ROBERT ALAN VOGEL

897

FIGURE 7. RAV (right) with Bertram Pitt (left) and Merck Fellow and close friend, Fred Aueron, at the University of Michigan.

me was about as different from college physics and math as you could imagine. In college, our exams were open book. You simply had to solve problems. As usual, my first day in medical school started with anatomy. My lab partner and I were given a cadaver and we began dissecting. Having never done much biology, the concept of memorizing a lot of unconnected facts was unusual. I liked physiology better because at least it made sense. The second big difference was that our learning involved people, and the knowledge base allowed you to help them. That’s what I was looking for. Physics was very impersonal. If you found a new particle, OK. If not, there was no consequence. Now I was learning science relevant to people’s well being. WCR: Who were some of your classmates in college or medical school who have done well? RAV: Sid Smith, who was the head of cardiology at UNC, was in my class. A past CEO of our hospital, Steve Schimpf, was also a classmate. I continue to be friends with Sid because of our mutual interest in preventive cardiology. Robert Peters, who directs our VA cardiology program, was also a college classmate. WCR: What did you do in the summer when you were at Yale Medical School? RAV: For the first summer, I went back to camp where I ran the waterfront. After my second year, I took part in a wonderful program that had been set up in Waterville, Maine. I lived nearby in China, which is 898 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

a very small, rural community, with a psychiatrist who had been shot by 3 of his patients while working previously in Manhattan. I worked with a series of physicians in different specialties—pediatricians, internists, surgeons, and psychiatrists. I spent a couple of weeks with each. We got to see what basic medicine was like. I went into towns where there were no physicians. I still remember helping out in an office on a very remote island off the Maine coast. When we had to do a throat culture, we would go out behind the facility where they kept sheep and do a jugular puncture. We used the sheep blood to make blood agar plates for culturing. It was as primary medicine as you could imagine. It was a wonderful way to learn the other side of medicine. One world was New Haven Hospital and the other was China, Maine. WCR: Did you like New Haven? Did you like the atmosphere at Yale? RAV: I loved Yale, itself. The self-paced learning process was wonderful. New Haven was not attractive, but it was a nice area being on the seacoast. I spent time sailing, which I still love to this day. We live on the water near Annapolis and I have a small sailboat and a larger sailboat, as well as kayaks. I did some crewing and racing then. To the north were the ski areas. We spent a lot of time skiing in medical school. WCR: When did you learn to ski? RAV: I learned to ski in college. I skied all through APRIL 1, 2004

FIGURE 8. RAV with wife Sharyn.

medical school. My love of skiing influenced my decision about internships. I went to Colorado, at least in part because it is a nice outdoors sports area and has the best skiing in the world. WCR: Who had impact on you in medical school? RAV: Two cardiologists there had impact on me— Larry Cohen and Allan Goodyear. The cardiovascular person I best remember was William Glenn. Bill Glenn (the Glenn procedure) was a character. He was famous both for how slowly he operated, and for a number of truly innovative concepts. He was my first model of a medical person who created new things. That innovative spirit had an impact on me because he was changing practice. Cardiology in the 1960s and 1970s very much followed this inventive track. WCR: Did you have a hard time deciding which area of medicine to go into? Did internal medicine come naturally to you? You were a tinkerer and liked Bill Glenn. Was surgery attractive to you? RAV: I thought long and hard about going into cardiac surgery. Two other people who had a large impact on me were the chiefs of medicine at Yale at the time—Phil Bondy and Paul Beeson. Phil Bondy had been the bugler at my camp, years earlier. Both were very accessible and had considerable impact on me. They did rounds with us and had strong presences in the weekly conferences (the Clinicopathological Conferences and others). These conferences were great challenging discussions, especially about diagnostic medicine. At the last moment I decided on

internal medicine because it seemed more intellectually challenging than surgery. WCR: You mentioned you chose Colorado, maybe because of attractive outside activities. Did you apply to a number of internships? RAV: My first choice was Moffit (University of California at San Francisco) and my second choice was the University of Colorado at Denver. I was moving west in any case. I don’t remember applying to any hospital on the East Coast. I wanted to go west to get a different feel of the country and experience a different kind of school. WCR: Had you ever been out there before? RAV: I had. I had spent one summer in Berkeley. I had been all around the country with my swimming teammates in college. WCR: For the swimming team? RAV: Yes, we swam various venues. But more importantly, my teammates were my buddies in college. The team was a ready-made fraternity in that sense. I spent 4 hours a day with those guys, let alone whatever amount of time I spent in class with them. It was a wonderful experience. Gary Nyman, a swimming teammate, remains a friend. He is a psychiatrist living in Baltimore. We had the internship match even in those days, and the decision was made for me. I went to Denver. WCR: How did Denver work out? RAV: Denver worked out very well. The internal medicine program was small, but very good. The person who had the greatest impact on me was Edward Genton, the associate chief of medicine under Gordon Micklejohn. Ed ran the residency program in my years and was the principal educator. He went on to be chief of cardiology at the Oschner Clinic in New Orleans. He was a very hard-driving, intellectually challenging fellow. I remember one night getting 6 sick patients admitted to me after midnight and Ed’s first question was, “Tell me about their social histories.” It was a very challenging experience. These were the days when you were on call every other night and it was hard work mentally and physically. Ed probably was the reason I went into cardiology. In my last year of residency, Ed got me a research grant from the American Heart Association to work with Richard Spangler. I designed and built an artificial heart. It’s not what you usually call a starting project, to say the least. The prototype actually worked in calves for short periods. My research projects in medical school and residency reinforced my impression that innovation was the key to research. Cardiology with its mechanical basis was a natural for a physics person like me. WCR: What year was your internship? INTERVIEW/ROBERT ALAN VOGEL

899

FIGURE 9. RAV with daughter Elizabeth.

RAV: It started in 1967. I did 4 years. I finished in 1971 and then went into the Air Force for 2 years. We all had to do service time then. I had a wonderful tour of duty at the Air Force Academy. I, along with 4 other internists, ran the hospital at the academy. We literally did everything we had experienced in residency. We managed patients with myocardial infarctions and renal failure and administered chemotherapy. Along with a few physicians at other bases, I was asked to start a physician-assistant training program for the Air Force. It was a time when the concept of physician’s assistant was in its infancy. We trained 2 physician’s assistants at a time at the Air Force Academy. We had to design a curriculum from scratch for a career that was not yet well defined. The corpsmen coming back from Viet Nam had terrific hands-on experience, but no academic certification. I was impressed how quickly they learned and how hard they worked. WCR: At the Air Force hospital you took care of the students at the Air Force Academy? RAV: We took care of the students but that didn’t take much of our time because they were pretty healthy. The hospital is located in an area where many retired military people live and we had other military bases that we serviced for secondary care. It was basically general internal medicine. WCR: That’s only 60 miles or so from Denver. RAV: Yes. During my service time I maintained a 900 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

good relationship with the faculty at Colorado. After my service, I went back to the University of Colorado for my fellowship. WCR: After you finished cardiology at the University of Colorado you were asked to stay on the cardiology faculty? RAV: Yes, but that was a bit of an accident. Although I had had some productive research experience, I always thought that I would go into practice. At the beginning of my last year of fellowship, the head of cardiology at the Veteran’s Administration, Peter Steele, came to me and said, “Bob, I know you want to go into practice, but would you run the catheterization laboratory at the VA Hospital for at least a year or 2? (Figure 6). You can go into practice after that.” Peter was the only true academic cardiologist at the University of Colorado at the time. He was a terrific grantsman and prolific writer. Of all the folks who influenced my career, Peter Steele had the greatest impact. Peter, who remained in academic medicine for about 10 years before going into private practice, was a very inventive young fellow. In the early 1970s, he was very interested in platelet function and nuclear medicine when these were very seminal concepts in medicine. I credit Peter with asking the question that started my academic career. We were just starting to use a new substance, thallium, for a new technique, myocardial perfusion imaging. The early planar thallium images barely visualized the heart. Seeing perAPRIL 1, 2004

FIGURE 10. RAV with close friend Allan Ross.

fusion defects was a hit or miss affair. Peter asked: “Bob, make these pictures better.” He didn’t tell me how; he just told me to make them better. As a solution, I thought, “Coronary perfusion is a segmental process. Let’s do tomographic imaging.” I thought of my dad and the fact that if computed tomography had been available, his cancer could have been diagnosed earlier. I was physics trained, so this was a natural. We invented a technique called 7-pin-hole tomography, which was the first practical single-photon emission computed tomographic technique. It could be performed using standard nuclear cameras of the time. Remember, we were in a VA hospital and everything had to be done in a very low-budget fashion. Along with 2 engineers who were already part of cardiology—Dennis Kirch and Michael LeFree—we set about inventing single-photon tomography. Within a few weeks, we were making pretty good tomographic images that were clearly superior to the planar ones. Shortly thereafter, we developed the circumferential approach to interpreting thallium images and gated imaging for wall motion. That was really the start of clinically effective myocardial perfusion imaging. We did all this very quickly, mostly because we didn’t know that it couldn’t be done quickly. We had a PDP-12 computer, which was as big as a mediumsized room and cost about $100,000. It was about as powerful as today’s wristwatches. I remember programming the computer using punch tape. It was very

primitive. Today we do rotational tomography using very fast computers. But it all started with 7 holes in a sheet of lead and some basic concepts that have held up. That’s how I got started in academic medicine. WCR: It sounds to me like you had that innovative curiosity when you were a kid, making all those things and taking machines and clocks or whatever apart and putting them back together. You never did any research in college? Is that correct? RAV: Yes and no. I never did real research in college, but I spent 1 year on a thesis dealing with continuous versus quantized circuit theory. Mel Schwartz let me do this independent project instead of taking the usual lab course, which involved many of the projects I had done in my basement. It turned into a very lengthy thesis and I was graded very highly on it. It was completely self-study. It was in the educational mode of “take a problem and solve it yourself.” WCR: You got into thallium your first year as a faculty member? RAV: Yes. It wasn’t my first project. I’d done some collaborative work using digitalis in ischemic cardiomyopathy. My first independent project was thallium tomography. Although our first manuscript on single photon tomography was published in the Journal of Nuclear Medicine, the second manuscript, which included the idea of quantitation, was in The American Journal of Cardiology (AJC). Over the years a lot of INTERVIEW/ROBERT ALAN VOGEL

901

FIGURE 11. RAV with close friends William Spencer, III (center) and James Forrester (right)

innovative ideas like that have been first published in the AJC. WCR: When did you meet your wife? RAV: I met my wife as a blind date in Denver. I had just started my fellowship and we had a friend in common, John Hutcherson. John is a cardiologist in private practice in Colorado and is a friend of ours to this day. My wife was a nurse at a local hospital. I knew on the first date that I was going to marry her. I don’t know if she had the same feeling. WCR: When did you get married? RAV: We got married in 1975, 2 years later. WCR: What were her characteristics that attracted you like a magnet so quickly to her? RAV: Bill, you know my wife, Sharyn. My wife is one of the most lovely, intrinsically social people I know. She “collects” people. She collects colleagues of mine. She collects neighbors. She collects strangers on airplanes. She still is in contact with her friends from high school. At any time of day, one of these people may call her, just to chat. She is an incredibly warm and social individual. She is Irish and has the gift of gab of the Irish. She’s a wonderful storyteller. It was just a very comfortable relationship from the first moment that I met her. Within an hour or 2, it was a very comfortable relationship. That has not changed. WCR: You were on the faculty at the University of Colorado for how long? RAV: Five years. I got tenure there the fourth year. 902 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

Then, Bert Pitt asked me to come to the University of Michigan (Figure 7). Bert had done some pioneering work in radionuclide angiography while I was working on thallium. Bert had just moved to Michigan and he offered me the head of the VA Hospital there. He was a great boss. The chief of medicine was Bill Kelley, who also was an excellent administrative model. This was a time when the University of Michigan Medical Center was growing and recruiting young people in cardiology. I credit Bert with having gathered one of the most productive cardiology faculties ever assembled. Bert was a tremendous recruiter and supporter. Bert had a knack about him. He’d find good folks—Eric Topol, Bill O’Neill, Cindy Grimes, Jeff Leiden, Andy Buda, John Mancini—a lot of folks that have done very well in cardiology, and he would give them independence. He’d say, “Develop this program.” And you would get credit for it. He made sure that if you did something well, he wouldn’t take the credit; it was your recognition. WCR: Are you talking about Bert or Bill Kelley? RAV: Both were similar in that regard, but Bert had a tremendous talent for finding good folks and encouraged them. He has been recognized for these abilities, but probably not as much as he deserves. He was the second person with whom I worked who really had a tremendous impact on me. When I was at Michigan, we developed a nice program at the VA Hospital, with 8 research-funded faculty. My interests migrated from APRIL 1, 2004

FIGURE 12. Close friend John H.K. Vogel at the top of the Snowmass Ski Resort trail named by RAV and John Schroeder in his honor.

nuclear to digital imaging. We had the first digital radiographic catheterization laboratory there. We were the first to do quantitative arteriography and contrast myocardial appearance studies on-line, foreshadowing concepts, such as the Thrombolysis In Myocardial Infarction trial flow grading, which now are commonplace. Many of the techniques that came out of this early experience with computerized imaging in the cath lab started at Michigan. WCR: When you were in Colorado, you spent a great deal of time in the cath lab. Did you do interventional procedures at that time? RAV: Yes. I spent a lot of time in the cath lab at Michigan. Angioplasty was coming into full swing at that time. We had also started doing primary angioplasty in patients with acute myocardial infarction. Michigan played an important role in popularizing that concept. We were learning how to use computers on-line to review images and to quantitate flow and arterial stenoses. It was quantitative arteriography that got me interested in atherosclerosis through disease progression studies. That is how I got into vascular biology and preventive cardiology. Two things happened almost at the same time. One was writing the first automated program for quantitating coronary stenoses. Greg Brown, who started the concept, had been doing it with hand tracings. The second factor was pure accident. In 1983, my friend Allan Ross was

supposed to give a talk on cholesterol lowering at Jack Vogel’s Snowmass meeting. Allan came to me and said, “Bob, I don’t think there’s anything to this cholesterol lowering. Why don’t you give this talk?” I said, “Okay, I’ll look into it.” In the early 1980s there weren’t many cardiologists interested in cholesterol. I started reviewing what few data there were available and it looked promising. Remember, this was before any of the angiographic trials and statins. Preparing that talk got me interested in preventive medicine. We had the tools to measure progression of disease because we were quite familiar with quantitative arteriography. WCR: How did Ann Arbor, Michigan, hit you after living in wide-open Colorado for so many years? RAV: Sharyn and I (Figure 8) also enjoyed Ann Arbor, but for different reasons. Our daughter spent her junior and high school years there in good public schools (Figure 9). There was little opportunity to ski, but we canoed often on the Huron River. Nearby Detroit was not as much fun as Denver had been. The university sports there were wonderful, although we realized that we were a mixed marriage. I was on the Michigan faculty and my wife had grown up in Columbus, Ohio. I did well academically and within about 5 years other nice job opportunities presented themselves. INTERVIEW/ROBERT ALAN VOGEL

903

FIGURE 13. RAV and namesake hiking in Colorado.

WCR: How did the University of Maryland come

about? RAV: I had been invited to visit a few programs as potential division head. Before going to Maryland, I had looked at the University of Texas Medical Branch at Galveston, The University of Cincinnati, and Wayne State. A surgeon at Maryland, Doug Behrendt, told John Kastor, then the Chief of Medicine, about me. John Kastor invited me to look at the program. I saw a program that had a lot of potential and therefore took the position. WCR: How did it work out? You went there in 1986? RAV: I became acting director there in the summer of 1986, sharing my time with Michigan, and moved there full time in 1987. WCR: You had been promoted to full professor at the University of Michigan in 1985. You were flying, so to speak, in your professional career. RAV: Yes. We had had a productive run at Michigan. At Colorado, we had been innovative with nuclear cardiology. At Michigan it was invasive imaging. I was clearly at the right place at the right time in both instances. The Maryland program was a small one and nonacademic. Only recently had the Veterans Administration and the University fellowship programs been brought together. I had a supportive chief 904 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

of medicine and a lot of opportunity to recruit faculty because there were a lot of open positions. We only had 6 full-time staff in cardiology when I got there. When I stepped down in 2000, we had grown to 21. WCR: You were the chief from 1986 to 2000? RAV: Yes. WCR: Did you enjoy being chief of cardiology there? RAV: Yes. Bill, I very much enjoyed being the chief of cardiology. It was a very different academic environment than now. As long as you didn’t commit a major felony, it was difficult not to be a good chief of cardiology because cardiology was progressing so rapidly. I was able to recruit some excellent faculty, who continue to do well in academic cardiology— Michael Gold, now chief of cardiology at South Carolina, Andy Ziskind, now associate dean at the University of Washington, Mary Corretti, now director of echocardiography at Johns Hopkins, Steve Shorofsky, who runs our electrophysiology program, Steve Gottlieb, who runs our heart failure program, and Michael Miller, who heads our preventive program. We had terrific teachers, namely Gary Plotnick and Mike Fisher, and excellent clinicians, such as Mike Fisher and Mike Benitez. Within 5 years or so, we had an excellent electrophysiology program and good programs in heart failure, cath, prevention, and echo. I look back on those 14 years as an enjoyable time, a building time, a time when cardiology came together. By the end, it had become more difficult because of the growing financial and regulatory constraints throughout academic medicine. I feel fortunate to have run a program during academic cardiology’s golden era. WCR: What was your day like when you were head of cardiology at the University of Maryland? I know no 2 days were exactly alike, but, in general, what time did you wake up in the morning? What time did you get to the hospital? What time did you leave the hospital? What time did you get home? What were your evening activities like? RAV: I’ve always gotten up at 6:30 A.M. I was usually at the hospital by 8:00 A.M. Fully half of my day when I was chief of cardiology was administrative, which meant meeting with individuals and committees, recruiting, programmatic development, and dealing with hospital administrators. We had 21 faculty and 120 fellows, nurses, technicians, and secretaries. There was always something administrative to be done. I maintained a clinical practice through those years and attended for 3 or 4 months each year. My research programs also continued but I took myself out of the cath lab. As time went on, I was asked to give more talks. I had done some speaking at Michigan, but much more at Maryland. Grand rounds and continuing medical education courses in cardiology really flowered in the late 1980s and 1990s. I enjoy speaking and taking part in conferences very much. A number of my closest friends are a result of speaking— Jack Vogel, Jim Forrester, Allan Ross, and Bill Spencer (Figures 10 to 12). We have spent a lot of personal and professional APRIL 1, 2004

FIGURE 14. RAV (background) with University of Maryland faculty Drs. and Mrs. Andrew Ziskind (left), Michael Fisher (center), and Gary Plotnick.

time together in truly wonderful places (Figure 13). My wife Sharyn and family have become very much a part of these friendships, along with their wives and family. We truly love each other. We go to the weddings and the graduations of their kids, all of whom we know fairly well. We ache when something bad is going on and we cheer when something good happens! This group is a gift that cardiology gave me—a fraternity of very close friends and colleagues. WCR: How much do you travel a year now? How many trips do you go on outside of Baltimore each year now? RAV: I probably do 30 or 40 trips a year outside of Baltimore. Each trip might be for a single grand rounds, but it might be for a week-long conference. I do a fair amount of traveling. WCR: You obviously didn’t have that much time when you were chief of cardiology to do that? RAV: No. As chief, I didn’t have that much time. Since I stepped down I have traveled more frequently. Recently, I have started to travel less because of my interests at home. WCR: When you were chief of cardiology, how late were you at the hospital as a rule? RAV: I went in at 8:00 A.M. and probably started home about 7:00 P.M. WCR: After dinner, were you any good from a professional standpoint?

RAV: I always brought work home to do after dinner. I did a lot of my writing and some of my reading at home. I need to write without interruption, but I love to write. To allow me to write in the office, I’d close my door and hold telephone calls. Since the advent of laptops, I do a lot of writing on trips. WCR: You do your writing entirely on a computer now? RAV: Yes. WCR: So you’re not dependent on anybody? RAV: Yes. What’s also nice about computers is that I can keep a lot of my references and data on the computer. I probably have 2,000 slides and more than twice that in references on my computer. When I sit down to write something, it’s all there. It’s a wonderful writing help. WCR: When you came to Baltimore, did you give up the cath lab right away? RAV: Yes. That was the first thing I gave up. I think that the cath lab should be a full-time job. I don’t think it’s a once-a-week endeavor. When I need to do percutaenous coronary intervention, I’m going to have somebody who lives in the cath lab do it. I used to live in the cath lab and I know what that means. I didn’t give up clinical medicine. I still attend in the coronary care unit and on consulting services. I miss the cath lab a little bit because it was fun. WCR: How often do you see patients in a clinic? INTERVIEW/ROBERT ALAN VOGEL

905

FIGURE 15. RAV (left) with wife Sharyn, and Joellen and Michael Gold now at the Medical University of South Carolina.

RAV: I see my own patients one morning a week by myself. I don’t want a fellow to see them first because it lessens the personal contact. I know my patients very well. I’ve had some of them as patients now for 15 years. That’s the best part of medicine. The attending is still enjoyable, although not as much fun as it was because of the unnecessary and redundant charting. WCR: What do you do on the weekends now? RAV: We live on a small island and have our own boats and pier. On weekends, we usually do something outdoors. We often have friends over for dinner or eat out. I try to get some sporting activity in, either golf or tennis. WCR: What’s your golf handicap? RAV: My handicap is every aspect of my game, Bill. I’m an 18 handicap. I don’t think of myself as a terribly good golfer, but I do enjoy it. WCR: Where do you live now? RAV: We have moved twice in Baltimore. When we first came to Baltimore we lived in the heavily wooded northern suburbs in a new area. Soon after that, we moved to a wonderful part of the city, Roland Park. It’s an area of big old houses with huge trees. Anne Tyler writes her books about Roland Park. It is a very friendly area. There is a terrific community there, lots of parties where people know everyone else (Figures 14 and 15). We spent 10 years in Roland Park. 906 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

Two years ago, we moved to the Annapolis area. We found a small island on which we were able to build a house that looked out at the water in all directions. Sharyn and I had a real division of labor building the house. She designed it, got the architect and contractor, and furnished it—and I paid for it. Living on the water is tremendously rejuvenating. I try to come home before sunset and have a drink out on our patio and watch the sun go down. I have 2 sailboats. We have 4 kayaks and we kayak around the island, which takes about 1 hour. We have ospreys, bald eagles, swans, herons, geese, and ducks. We put in an osprey pole right off our dock. Every March the osprey return, build a new nest, and raise 2 fledglings. It’s fun to watch. WCR: Your house is about 45 minutes from Baltimore? RAV: It’s a 45-minute drive to the hospital. I do the drive usually twice a day, but sometimes we stay at our condominium in Roland Park. The drive is more than I would like, but living on the water is worth it. WCR: When you lived in Roland Park, was it 10 minutes to the hospital? RAV: More like 15 to 20 minutes. WCR: What do you do when you have this 90 minutes in your car? RAV: I either listen to a tape or to National Public Radio, which I enjoy. WCR: Bob, your career in cardiology has intrigued APRIL 1, 2004

WCR: What do you eat every day? What are a typical breakfast, lunch, and dinner for you? RAV: I am pretty much a poster child for good boring eating. Ninetyeight percent of the time I have cereal (Raisin Bran, Shredded Wheat, or Cheerios) with skim milk and orange juice for breakfast. Recently I’ve taken to watering down the juice a little bit to decrease the glycemic load. Lunch usually is a big salad topped with tuna. In the last few months, our hospital has put in a good sushi bar, which gives me some variety at lunch, but I still have a salad. WCR: What kind of dressing? RAV: That’s a very good point. I use a small amount of olive oil and a lot of vinegar. I’d rather have canola oil than olive oil on it, but it’s unusual that you can get canola oil in restaurants. My wife is a world-class cook. For dinner, we’ll generally have fish, occasionally chicken, or once in a while, red meat. We always have a nice big salad. Until about 8 or 9 P.M. I’m a good boy, but before we go to bed, my wife and I FIGURE 16. RAV with wife Sharyn at the marriage of their daughter Elizabeth and generally have 1 or 2 scoops of ice Robert Helgans III. cream, often homemade. We figure we’ve earned it by that time. me for a long time. You started in the nuclear area. WCR: That’s your sweet for the day? You were in the cath lab for a long time. You became RAV: Yes, I don’t like snacking and I’m not really an interventionalist. You did quantitative coronary big on sweets. I try to stay away from sugar. I really angiography and reversibility studies. Then you be- don’t eat any junk food. I will have a handful of nuts come a major proponent of preventive cardiology and with my wine when I get home. a major leader worldwide in this area. As you look WCR: What medicines do you take? back over your professional career, what has brought RAV: I have taken a statin for a long time. I started you the greatest happiness professionally or the great- in 1990 when their use was pretty new for folks est sense of accomplishment? What are you most without coronary disease or for those who didn’t have proud of? terribly high cholesterol values. Even on a good diet, RAV: There are 3 developments over the years of I don’t have the best cholesterol. It’s ranged between which I am proud. Early on, by implementing single- 200 and 220 mg/dl. We have studied our faculty’s photon emission computed tomography and quantita- endothelial function at these levels. Our endothelial tion, we made thallium imaging clinically useful and function improved every time we lowered our cholespractical. More recently, we were among the first to terol. In studying ourselves, we quickly learned how realize that truly “normal” cholesterol is much lower harmful a cholesterol level of 200 mg/dl could be. My than originally thought. Today, I would say that bio- LDL cholesterol 2 months ago was 58 mg/dl, which is logically normal low-density lipoprotein (LDL) cho- where I’d like to see it. My high-density lipoprotein lesterol is ⬍60 mg/dl for about half of the population (HDL) is about 75 mg/dl. and that normal total cholesterol is ⬍150 mg/dl. Only WCR: That’s the best. Your HDL is higher than when these numbers are achieved is endothelial func- your LDL. tion optimal. Third, we discovered the immediate efRAV: Yes, that’s really ideal. We talk a lot about fect of an improper diet on vascular biology. We were LDL, but getting HDL up is also very important. I still the first to show that fat and subsequently high-sugar may die of coronary disease. Who knows? But at least diets are directly injurious to endothelial function. We I’ve done the kinds of things I think I’m able to. I’m now understand that the postprandial state is very not on an aspirin. I’ve reasoned that with so low an atherogenic. Understanding this concept tells us that LDL, the risk would be more than the benefit from it. we not only have to lower our cholesterol values, we WCR: An 81-mg aspirin tablet doesn’t hurt many have to eat correctly. Today, there is so much non- people, does it? RAV: It hurts some. I have diverticuli. I haven’t sensical dietary advice. INTERVIEW/ROBERT ALAN VOGEL

907

bled, but I would rather not take the chance. Every once in a while one sees bleeding at that dose. I’m not sure whether low-dose aspirin is useful at low risk. I think that a statin is safer than aspirin. WCR: You have indicated that atherosclerosis is a proliferative, inflammatory, and thrombotic disease. Aspirin hits the latter 2 of those 3. Do you think that the lowering of lipids decreases the clotting tendency? RAV: Yes. I think it does. At an LDL of 60 mg/dl, there is less coagulation than at 130 mg/dl. There are some post hoc data from the Physicians’ Health study that C-reactive protein can be used to determine the benefit from aspirin, but it needs confirmation. WCR: And your blood pressure is such that you don’t need or you don’t take antihypertensive medicines? RAV: Fortunately, my systolic blood pressure is still 110 or 115 mm Hg, even when I’m busy in the hospital. My diastolic pressure is in the 70- to 80-mm Hg range. I can’t tell you why it’s remained that low. My mom has a pretty good arterial pressure at age 96, so I may have inherited it from her. WCR: How often is atherosclerosis genetic in origin and how do you define the genetic variety of atherosclerosis? RAV: How we are currently determining it and how we will be doing it are very different. There are a lot of undiscovered genes involved and we’re going to use gene screens in the future. Currently, we define it by family history of disease and a few familiar dyslipidemias, but I think it’s much more complex than that. Like most people, I have neither a strong nor a weak family history. My grandfather had coronary heart disease. My father didn’t, but he died of cancer. My mom doesn’t, so I hope I get more of her genetic predisposition. Heredity plays a role primarily through the expression of other risk factors— hypercholesterolemia, hypertension, diabetes mellitus, and obesity. But, I think there’s a component of heredity that’s only evident in genetic analysis. That’s what we’re starting to get into because we know that each person responds differently to the same risk factors. It’s not just what our cholesterol level is, but how each of us responds to that level. We currently have a genetic linkage study in the Amish to learn why people respond differently to a high-fat diet, cold pressor stimulation, salt, and aspirin. We’re not only interested in the atherosclerotic risk factors, per se, but how people respond to them. That’s also an important part of heredity. WCR: Bob, you are obviously at ideal body weight. How do you maintain ideal body weight? RAV: I have played tennis at least once a week since age 20 or so. I only play singles. It keeps me in shape. I also sail, play some golf, and ski. I really enjoy being physically active. In the last year, I’ve taken up the Ken Cooper 10,000 steps program, which I like. Some of our faculty have done the same. We usually wear pedometers. When I get home at the end of the day, I’ve walked anywhere from 4,000 to 10,000 steps. Sharyn and I go for a walk on the island before or after dinner if I’m not at 10,000 steps. We 908 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

FIGURE 17. The next generation, daughter Elizabeth and newborn granddaughter Delaney.

really need to encourage more physical activity of every variety, but walking is the easiest. If I’m on consults, I’ve gotten in 10,000 steps by 2:00 P.M. If I’m in the coronary care unit or in my office, I get in only about 4,000 steps by the time I get home. Then, I’ve got to go out and walk. WCR: Cardiology today is a very broad arena. There is echocardiography, arterial intervention, electrophysiology, nuclear cardiology, etc. Bob, what do you recommend for the cardiology fellows who are finishing today? How do you envision angioplasty, stents, bypass, and these major procedures 20 or 30 years from now? RAV: I think that these procedures will still be going on to some extent. I really believe in subspecialization. You need to live in the cath lab. If you’re going to do electrophysiology, you need to live in the electrophysiology lab. I don’t recommend the jack-ofall-trades cardiologist who puts in pacemakers, does some catheterizations, reads some echoes, and does some nuclear studies. I know that this approach is personally rewarding, but I don’t think it’s good for patients. Noninvasive cardiology is more than enough by itself. There is plenty to do in the office and hospital between imaging and patient care. Cardiology has become such a broad area that we need to be subsubspecialists. The same is true of academic practice. Despite the increasing financial demands, academics is still really about discovery and innovation. APRIL 1, 2004

The happiest academicians I know still get grants and write papers. WCR: You are how old now? RAV: Sixty. WCR: What are your plans for the next 30 years? RAV: I’d certainly like to have plans for the next 30 years. If I inherited my mom’s genes then that’s a possibility. Right now I’ve taken on 2 new activities, one of which is writing. I love to write. I’m currently writing a book entitled, “Virtual Blondes, Dog Walking, and Canola Oil.” It’s a lay book for Americans wishing to improve their lifestyles with respect to heart disease. I’ve done it as a labor of love. I don’t know whether it’s going to be popular or not, but if not, we’ll give it away. We need to change the American lifestyle. I’ve just started working with Archie Roberts to popularize preventive medicine in young people. These 2 kinds of activities are something that I see myself doing more of. WCR: How much time do you take off now each year? RAV: That’s a tough question to answer because I almost never just go on vacation. In the last 15 years, I have probably had ⬍10 weeks of pure vacation. I certainly go to a lot of wonderful places with Sharyn and give talks. These activities have become vacations for us. We now have a granddaughter, Delaney Grace (Figures 16 and 17). For the first time in my life I’m starting to just go out and spend some time without any professional activity connected to it. WCR: She’s in Denver? RAV: She is in Denver. She’s 4 months old. My son in law is finishing up his training in radiology at the University of Colorado. He will go into practice in July 2004. We head to Denver at every opportunity without the computer or any professional event attached to the visit. Up until now, I have never known pure vacation. It’s not that we don’t get time in nice places, but it’s basically been work all the time. People in medicine work very hard. Physicians in academic medicine work hard. That’s fine. I enjoy what I’m doing. I get rewards from it. Now I’m beginning to think for the first time of just taking time off, period. WCR: Do you plan to work forever? RAV: I’d like to work part time for as long as I can. Part time is not easy to do. They don’t advertise many part time jobs in medicine. I’d like to continue to do research. I’d like to have a hand in clinical medicine. I’d certainly like to write and I’d like to give talks. I just don’t know how to do that part time. If I figure that out, I’ll let you know because that’s what I really want to do for the next 30 years. WCR: Do you think coronary artery bypass operation is going to hang in there? RAV: It’ll hang in there. Whether we’re going to do the thousands of procedures each year that we currently do in this country, I don’t know. The percutaneous interventions will get better as will the preventive aspects. Preventive medicine has had more impact than all the bypasses and angioplasties put together. I

wrote an editorial on that subject ⬎10 years ago. It is finally coming to be true. WCR: Is there anything you’d like to talk about that we haven’t discussed? RAV: I certainly want to give my wife Sharyn her due credit. No one has a career alone. It has been wonderful sharing what I’ve done with Sharyn, who has been very supportive person. When I was chief, she did the entertaining. She frequently goes to meetings and is the heart of our social life. She is the epitome of the humanistic qualities I looked for in medicine. I also have the world’s most wonderful daughter and great son-in-law, and now a granddaughter. When I look back, my family has been the best part of my life. WCR: How did your parents take your initial move to Denver? RAV: They took it as the end of the world to be that far away. My parents thought the world ended just beyond the Hudson River. I never thought that moving west was a problem. I wanted to see more of the world. I guess that turnabout is fair play. Now our daughter lives in Denver with our granddaughter and I can well understand my parents’ perspective. WCR: Bob, on behalf of the readers of The American Journal of Cardiology, I want to thank you for being so open here and I’m sure the readers will get a great deal out of this. RAV: Thank you, Bill. It’s been a pleasure. SELECTED PUBLICATIONS OF RAV SELECTED BY RAV* 6. *Vogel R, Kirch D, LeFree M, Steele P. A new method of multi-planar emission tomography using a seven-pinhole collimator and an Anger scintillation camera. J Nucl Med 1978;19:647– 656. 8. Steele P, Rainwater J, Vogel R. Abnormal platelet survival in men with myocardial infarction and normal coronary arteriograms. Am J Cardiol 1978;41: 60 – 62. 11. *Vogel RA, Kirch D, LeFree M, Rainwater J, Jensen D, Steele P. Thallium201 myocardial perfusion scintigraphy: results of standard and multi pinhole tomographic techniques. Am J Cardiol 1979;43:787–793. 13. Steele P, Rainwater J, Vogel R. Platelet suppressant therapy in patients with prosthetic cardiac valves, relationship of clinical effectiveness to alteration of platelet survival time. Circulation 1979;60:910 –913. 14. Vogel R. Quantitative aspects of myocardial perfusion imaging. Semin Nucl Med 1980;10:146 –156. 22. *Vogel R, LeFree M, Bates E, O’Neill W, Foster R, Kirlin P, Smith D, Pitt B. Application of digital techniques to selective coronary arteriography: use of myocardial contrast appearance time to measure coronary flow reserve. Am Heart J 1984;107:153–164. 25. O’Neill WW, Walton JA, Bates ER, Colfer HT, Aueron FM, LeFree MT, Pitt B, Vogel RA. Criteria for successful coronary angioplasty as assessed by alterations in coronary vasodilatory reserve. J Am Coll Cardiol 1984;3:1382–1390. 26. Vogel RA, Bates ER, O’Neill WW, Aueron FM, Meier B, Gruentzig AR. Coronary flow reserve measured during cardiac catheterization. Arch Intern Med 1984;144:1773–1777. 30. Hodgson JMcB, LeGrand V, Bates ER, Mancini GBJ, Aueron FM, O’Neill WW, Simon SB, Beauman GJ, LeFree MT, Vogel RA. Validation in dogs of a rapid digital angiographic technique to measure relative coronary blood flow during routine cardiac catheterization. Am J Cardiol 1985;55:188 –193. 35. Bates ER, Aueron FM, LeGrand V, LeFree MT, Mancini GBJ, Hodgson JM, Vogel RA. Comparative long-term effects of coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty on regional coronary flow reserve. Circulation 1985;72:833– 839. 36. LeGrand V, Hodgson JMcB, Bates ER, Aueron FM, Mancini GBJ, Smith JS, Gross MD, Vogel RA. Abnormal coronary flow reserve and abnormal radionuclide exercise test results in patients with normal coronary angiograms. J Am Coll Cardiol 1985;6:1245–1253. 43. *LeGrand V, Mancini GBJ, Bates ER, Hodgson JMcB, Gross MD, Vogel RA. A comparative study of coronary flow reserve, coronary anatomy and the

*References marked with an asterisk are of special interest. INTERVIEW/ROBERT ALAN VOGEL

909

results of radionuclide exercise tests in patients with coronary heart disease. J Am Coll Cardiol 1986;8:1022–1032. 49. Bates ER, McGillem MJ, Beal TF, DeBoe SF, Mickelson JK, Mancini GBJ, Vogel RA. Effect of angioplasty induced endothelial denudation versus medial injury on regional coronary blood flow. Circulation 1987;76:710 –716. 53. Vogel RA, Tommaso CL, Gundry SR. Initial experience with coronary angioplasty and aortic valvuloplasty using elective semipercutaneous cardiopulmonary support. Am J Cardiol 1988;62:811– 813. 55. Vogel RA. Assessing stenosis significance by coronary arteriography: Are the best variables good enough? J Am Coll Cardiol 1988;12:692– 693. 58. Vogel R, Shawl F, Tommaso C, O’Neill W, Overlie P, O’Toole J, Vandormael M, Topol E, Tabari KK, Vogel J, et al. Initial report of the National Registry of Elective Supported Angioplasty. J Am Coll Cardiol 1990;15:23–29. 60. *Beauman GJ, Vogel RA. Accuracy of individual and panel visual interpretations of coronary arteriograms: implications for clinical decisions. J Am Coll Cardiol 1990;16:108 –113. 67. Vogel RA. Comparative clinical consequences of aggressive lipid management, coronary angioplasty and bypass surgery in coronary artery disease. Am J Cardiol 1992;69:1229 –1233. 70. Vogel RA. Endothelium-dependent vasoregulation of coronary artery diameter and blood flow. Circulation 1993;88:325–327. 74. Folland ED, Vogel RA, Hartigan P, Bates ER, Beauman GJ, Fortin T, Boucher C, Parisi AF. The relation between coronary artery stenosis (assessed by visual, caliper and computer methods) and exercise capacity in patients with single vessel coronary artery disease. Circulation 1994;89:2005–2014. 76. MAAS Investigators. Effect of simvastatin on coronary atheroma: the Multicenter Anti-Atheroma Study (MAAS). Lancet 1994;344:633– 638. 80. Miller M, Konkel K, Fitzpatrick D, Burgan R, Vogel RA. Divergent reporting of coronary risk factors before coronary bypass surgery. Am J Cardiol 1995;75: 736 –737. 81. Corretti MC, Plotnick CD, Vogel RA. Technical aspects of evaluating brachial artery vasodilation using high-frequency ultrasound. Am J Physiol 1995; 268 (Heart Circ Physiol 37):H1397–H1404. 82. *Ellerbeck E, Jencks S, Radford M, Kresowick T, Craig A, Gold J, Krumholtz H, Vogel R. Treatment of Medicare patients with acute myocardial infarction: report on a four state pilot of the Cooperative Cardiovascular Project. JAMA 1995;273:1509 –1514. 88. *Vogel RA, Corretti MC, Plotnick GD. Changes in flow-mediated brachial artery vasoactivity with lowering of desirable cholesterol levels in healthy middle-aged men. Am J Cardiol 1996;77:37– 40.

910 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 93

90. *Vogel RA, Corretti MC, Plotnick GD. Effect of a single high-fat meal on

endothelial function in healthy subjects. Am J Cardiol 1997;79:350 –354. 94. Plotnick GD, Corretti MC, Vogel RA. Effect of antioxidant vitamins on the

transient impairment of endothelium-dependent brachial artery vasoactivity following a single high-fat meal. JAMA 1997;278:1682–1686. 95. Vogel RA, Corretti MC. Estrogens, progestins, and heart disease. Can endothelial function divine the benefit? Circulation 1998;97:1223–1226. 97. Marciniak TA, Ellerbech EF, Radford MJ, Kresowik TF, Gold JA, Krumholz HM, Kiefe CI, Allman RM, Vogel RA, Jencks SF. Improving the quality of care for Medicare patients with acute myocardial infarction. Results from the Cooperative Cardiovascular Project. JAMA 1998;279:1351–1357. 99. *Gottlieb SS, McCarter RJ, Vogel R. The effects of beta-blockade in high and low subgroups following myocardial infarction. N Engl J Med 1998;339:489 – 497. 101. Ziskind AA, Lauer MA, Bishop G, Vogel RA. Assessing the appropriateness of coronary revascularization: The University of Maryland appropriateness score (RAS) and its comparison to RAND expert panel ratings and American College of Cardiology/American Heart Association guidelines with regard to assigned appropriateness rating and ability to predict outcome. Clin Cardiol 1999;22:67. 102. Borer JS, Vogel RA. Bethesda Conference #30: effect of current national medical priorities and reimbursement on cardiovascular research activities in academic medical centers. J Am Coll Cardiol 1999;33:1109 –1120. 104. Vogel RA. Cholesterol lowering and endothelial function. Am J Med 1999;107:479 – 487. 106. *Vogel RA, Plotnick GD, Corretti MC. The postprandial effects of components of the Mediterranean diet on endothelial function. J Am Coll Cardiol 2000;26:1455–1460. 110. Corretti M, Anderson TJ, Benjamin EJ, Celermajer D, Charbonneau F, Creager M, Daley W, Deanfield J, Drexler H, Gerhard M, et al. Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the International Brachial Artery Reactivity Task Force. J Am Coll Cardiol 2002;39:257–265. 111. Fletcher GF, Balady GJ, Vogel RA: 33rd Bethesda Conference: preventive cardiology: how can we do better? J Am Coll Cardiol 2002;40:580 – 651. 112. Vogel RA. Vintners and vasodilators: are French wines more cardioprotective? J Am Coll Cardiol 2003;41:479 – 481. 114. Vogel RA. Heads and hearts. The endothelial connection. Circulation 2003;107:2766 –2768.

APRIL 1, 2004